BREAF IDEA ON PRESCRIBING OCP

1. Oral contraceptive Pills
(OCPs)
---Dr. Safikul Hasan,Demonstrator

2.  The combined oral contraceptive
pill (COCP), often referred to as
the birth control pill is a type of birth
control that is designed to be taken
orally. It includes a combination of
an estrogen (usually ethinylestradiol)
and a progestogen (specifically
a progestin). When taken correctly, it
works to prevent pregnancy.
Oral contraceptives (OCPs)

3. Oral contraceptives (OCPs)
 Approximately 80% of women will use
OCPs during their lifetime
 Success rate if instructions followed
perfectly - 99.9% first year of use
 Any missed pills - success rate 95%
 Adolescent’s success rate - 85-90%

4. OCPs - Estrogens
 Ethinyl estradiol (EE)
 Mestranol - 50 µg converted to 40 µg of
EE

5. OCPs - Progesterones
Progesterone Classification Family
• Ethynodiol diacetate
• Norethindrone
• Norethindrone
acetate
1st Generation Estrane
(short ½ life)
• Levonorgestrel (LNg)
• Norgestrel
2nd Generation Gonane
(longer ½ life)
• Desogestrel
• Norgestimate
3rd Generation Gonane

6. Mechanisms of action
 Estrogen component
 Inhibits ovulation by suppressing FSH & LH
 Alters secretions & cellular structure of
endometrial lining
 Prevents implantation

7. Mechanisms of action
 Progesterone component
 Inhibits ovulation by suppressing LH
 Thickens cervical mucous & impairs sperm
transport
 Alters endometrial lining
 Prevents implantation

9. TYPES OF OCPS

11. Monophasic pills
 Estrogen
 Progesterone
Day 21Day 1

12. Biphasic pill (Necon®)
 Estrogen
 Progesterone
Day 11

13. Triphasic pills
 Estrogen
 Progesterone
Day 8 Day15
Examples – Caziant®; Cylessa®; Necon 7/7/7®; Ortho-
Novum 7/7/7 ®; Ortho Tri-Cyclen ®; Tri-Sprintec®;
TriNessa®; Velivet®

14. Triphasic pills
 Estrogen
 Progesterone
Day 17 Day 6 Day 13
Day 7 Day 12
Day 8
Ex. Tri-Norinyl®; Aranell®; Leena®
Ex. TriNessa®; TriVora®; Enpresse®
Ex. Estrostep
Fe®; TriLegest
Fe®; Tilia Fe®

15. Monophasic, Biphasic or
Triphasic?
 Biphasic & triphasic pills were developed to
reduce side effects of monophasic pills
 Biphasic with norethindrone associated with inferior
cycle control compared to triphasic with
levonorgestrel [Cochrane Review 2005]
 Progestin may be more important than phasic type
 Monophasic pills give better cycle control
 Triphasic pills offer no physiologic advantage
 No data to support triphasic over monophasic pills

16. Progestin only pills
 Thicken cervical mucous & prevent sperm
ascending through os
 Erratic suppression ovulation
 Irregular bleeding more common
 Daily compliance crucial
 Same time every day (2-3 hr difference can
cause bleeding, allow ovulation)
 Are not contraindicated in smokers over
age 35

17.  Progestin only (Plan B®)
 0.75 mg levonorgestrel – two doses 12
hours apart
 Single 1.5 mg pill available (Plan B -
One Step®)
 Mifepristone single dose 600 mg within
72 hrs
Emergency Contraception

18. OCP general benefits
 Decreased
dysmenorrhea
 Reduced menstrual
flow
 Reduced risk of
anemia
 Improves acne
 Eliminate
mittelschmerz
 Decreased risk of
ectopic pregnancy
 Decreased risk of PID
 Decreased symtptomss
of PMS
 Improvement in
endometriosis
 Suppression of ovarian
& breast cyst formation

19. OCP – Benefit
 Endometrial cancer reduced
 50% reduction if used in prior 12 months
 Maximum protection if use continues for
3 years
 Protection lasts for 15 + years
 High or low dose pills provide protection

20. OCP – Benefit
 Ovarian cancer reduced
 40% reduction in risk over nonusers
 High dose or low dose pills - same benefit
 Begins after 3-6 months of use
 80% reduction after 10 years of use
 Reduced risk with family history ovarian
CA & 4-8 yrs. use

21. OCP Cardiovascular Risks
 Increased risk of CVD in smokers over
age 35
 Small increased risk MI with 2nd
generation progesterones
 Only with current users – no lingering effect
 Slight increased risk of ischemic stroke
 2-6 fold increase of ischemic stroke with
history of classic migraine

22. OCP - Risks
 Headaches
 May increase or decrease
 Headaches attributed to initiation of OCP tend
to improve over time
 If HA persists with normal BP & no focal deficit
 Lower dosage of estrogen, progestin or both
(no evidence effective)
 If HA persists with increased BP or focal deficit
 Discontinue OCP

23. OCP - Risks
 OCP use associated with increased risk
of developing systemic lupus
erythematosus (SLE)
 Especially if started recently [Bernier 2009]
 However, very low risk overall

24. VTE Risk
 VTE Risk
 3-6 fold increased risk VTE, highest first 6-12
months of use (SOR B)
 Older women have greater risk
 > age 39 - 100/100,000 person-years
 Adolescents - 25/100,000 person-years
 Obesity doubles the risk

25. VTE Risks
 VTE Risk
 Risk decreases with longer duration of use
 For same estrogen dose - desogestrel &
drospirenone have significantly higher risk
[Lidegaard 2009]
 Grapefruit juice can augment bioavailability of
EE [Grande LA 2009]

26. OCP Risks - EBM
 Risks (SOR B)
 Increase in cervical cancer after 8 or more
years of use after adjusting for HPV infection
 Risk of CIN 2 - 3 with oncogenic HPV
 Decreased with depot-medroxyprogesterone
(DMPA - Depo-Provera®)
 No association with combination OCPs
[Harris 2009]

27. OCP Risks/Benefits - EBM
 No increased risk of weight gain (SOR A)
 Weight gain does occur with DMPA – 5.1 kg
 No increased risk breast cancer (SOR B)
 No consistent change in breast milk
production (SOR A)
 Or in infant growth or weight (SOR B)
 Women who use OCP are not at an
increased risk of death later in life
 In fact a net benefit was found

28. OCPs can be used with these
conditions
 Diabetes mellitus
< 35 years old
 Nonsmoker > age 35
 Smokers < 35 years
old
 Obese women
 Caution > age 39
 Controlled hypertensive
 Ulcerative colitis
 Pituitary adenomas
 After gestational
diabetes

29. OCP Contraindications
 History of DVT, PE or arterial clotting
 Family history clotting or thrombotic events
 Family history (FH) if positive is risk factor VTE
 Ask if parent or sibling ever had VTE
 Positive FH if 1 relative was < 50 yo when VTE
occurred
 Positive FH if 2 or more relatives at any age had
VTE [Bezemer 2009]

30. OCP Contraindications
 Smoking and ≥ 35 years old
 Uncontrolled hypertension
 Migraine with aura
 Undiagnosed genital bleeding

31. OCP Contraindications
 Pregnancy – not harmful, just too late
 Sickle cell (SS) or sickle C (SC) disease
not absolutely contraindicated
 DMPA may be preferable for SS disease

32. Drug Interactions
 Vitamin C
 Increases estrogen level
 Can induce nausea
 Discontinuation of vitamin C may precipitate
bleeding
 Decreased estrogen level
 Antibiotics
 Unclear impact on efficacy

33. Drug Interactions
 Anticonvulsants
 Advise patients to use a different form of
contraception
 Because some anticonvulsants may reduce
efficacy of OCPs
 If you & patient decide to use OCP, use pill
with 50 µg EE
 If breakthrough bleeding occurs with that pill
 Patient should use alternative contraceptive
method

35. Starting OCPs – 2 Options

36. Missing pill instructions
 First ask which pill(s) were missed:
 If placebo pill just skip it
 If active pill and < 24 hrs late
 Take immediately
 If active pill and ≥ 24 but < 48 hrs late
 Take both pills at the same time
 Additional contraception not required

37. Missing pill instructions
 If 2 active pills missed
 Double up for 2 days
 Use additional contraceptive method for 7 days
 Consider emergency contraception if unprotected
intercourse
 If ≥ 3 active pills missed
 Stop pills and begin new pack
 Use additional contraceptive method for 7 days
 Consider emergency contraception if unprotected
intercourse
 Discuss alternative contraceptive options that do not
require daily compliance

38. Most Dangerous pill to Miss?
 Most dangerous pill to miss is
the 1st pill of the new pack
 Pill free > 7 days increases risk
ovulation
 Use additional form of birth
control until taken 7
consecutive active pills
 Stress compliance with starting
each new pack

39. OCP - Postpartum
 Can begin combination OCP ≥ 3 weeks
postpartum after delivery.
 Starting < 3 weeks postpartum associated
with increased risk of VTE
 Balance this against risk of unwanted
pregnancy which has greater risk of VTE
 For delivery of < 20 weeks gestation -
can begin combination OCP immediately

40. Contraceptive Failure Rate
Method Typical Use Perfect Use
No method 85% 85%
Diaphragm with spermicide 16% 6%
Condom – male 15% 2%
OCPs 8% 0.3%
Transdermal 8% 0.3%
Transvaginal 8% 0.3%
Injectable 3% 0.3%
IUD – copper 0.8% 0.6%
IUD – progesterone 0.2% 0.2%
Implant 0.05% 0.05%

41. Emergency Contraception (EC)
 Woman at risk for unwanted pregnancy
 Condom broke or slipped
 Forced intercourse
 Intercourse and no method of BC
 Diaphragm or cervical cap dislodged
 Two or more OCPs missed or forgotten
 > 12 weeks from last depo progesterone
injection
 Missed first pill of OCP

42.  Mechanism of action -
 Inhibits or delays ovulation if prior to ovulation
 Interferes with egg/sperm transport
 Alters endometrium and prevents implantation
Emergency Contraception

43.  Fewer side effects & better efficacy
 95% within 24 hrs, 85% within 25-48 hr
 Can be used up to 5 days after intercourse
 No clinical exam or pregnancy test is
necessary before EC
 EC may be used again even if used before
within the same menstrual cycle.
Emergency Contraception

44.  Ulipristal (Ella®) approved for EC
 Selective progesterone receptor modulator
(SPRM) – 30 mg single dose
 Remains equally effective up to five day after
unprotected intercourse
 Possibility it is less effective in women with
BMI > 30
 Requires a prescription
 No significant side effects but long-term data
is not yet available
Emergency Contraception

45. THANK YOU